• Secure Finance

  • Proposed Insured Information 

  • Format: (000) 000-0000.
  • Does the proposed insured have a valid driver's license?*

  • Beneficiary Information 

  • If Proposed Insured is a Child, Please Provide Parents or Legal Guardian Information 

  • Format: (000) 000-0000.
  • Does the Parent or Legal Guardian have a current Life Insurance Policy?
  • Format: (000) 000-0000.
  • Does the Parent or Legal Guardian have a current Life Insurance Policy?

  • Premium Information

  • Recent Applications, Inforce Coverage, and Replacement Information

  • Within the past 12 months, have you applied for or do you have any applications pending for life or disability insurance?*
  • Is the policy or rider being applied for intended to replace any inforce life insurance or annuity contract(s) including long term care insurance, disability income insurance or riders? Replacement includes surrender, lapse, reissue, conversion, reduction in coverage, premium or period of coverage of any life, disability income or annuity contract.*

  • General Information about the Proposed Insured

  • In the last 5 years, have you plead guilty to or been convicted of any moving vehicle violations or DUI or have you had a suspended license? (If yes, please give the details on the Remarks section)*
  • In the past 10 years, have you ever been convicted of a felony or misdemeanor? (If yes, please give the details on the Remarks section)*
  • Have you been or are you currently involved in any bankruptcy proceedings that have not been discharged? (If yes, please give the details on the Remarks section)*
  • Do you participate in any type of racing, scuba diving, aerial sports, mountain climbing, base or bungee jumping or cave exploration? (If yes, please give the details on the Remarks section)*
  • During the next 2 years do you intend to travel or reside outside of the USA for more than 2 weeks in a year? (If yes, please give the details on the Remarks section)*

  • Health Information about the Proposed Insured

  • Rows

  • • In the past 10 years, have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

  • Any disease or abnormal condition of the heart, circulatory system, high blood pressure, irregular heartbeat, murmur, rheumatic fever, coronary artery disease, chest pain, angina, transient ischemic attack or stroke? (If yes, please give the details on the Remarks section)*
  • Check all that applies
  • Any disease of the lungs or respiratory system, sleep apnea, emphysema, asthma, bronchitis, tuberculosis, allergies or disorder of the nose or throat? (If yes, please give the details on the Remarks section)*
  • Check all that applies
  • Any digestive system disease, including ulcer, chronic indigestion, liver, stomach, intestine or pancreas disorder, hepatitis, cirrhosis, jaundice, esophagus disorder, gallbladder disorder, or colon disorder? (If yes, please give the details on the Remarks section)*
  • Check all that applies
  • Any disorder of the nervous system, epilepsy, convulsions, paralysis, brain or eye disorders? (If yes, please give the details on the Remarks section)*
  • Check all that applies
  • Any spine, hip, knee, shoulder, back, bones, muscles, arthritis, rheumatism, joints, skin, thyroid, gout, or other gland disorder? (If yes, please give the details on the Remarks section)*
  • Any urinary system disease including protein, sugar or blood in urine, kidney infection or stones, disorder or disease of the breast, prostate or bladder, or pelvic organs? (If yes, please give the details on the Remarks section)*
  • Any depression, anxiety, bipolar,, schizophrenia, attention deficit disorder (ADD), or any other developmental or psychological condition including Alzheimer's, Dementia, or Post Traumatic Disorder (PTSD)? (If yes, please give the details on the Remarks section)*
  • Any anemia, hemophilia or disorders of the blood other than Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV)? (If yes, please give the details on the Remarks section)*
  • Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or have you tested positive for exposure to or been diagnosed with HIV or AIDS) (If yes, please give the details on the Remarks section)*
  • Any cancer, polyp, other tumors? (If yes, please give the details on the Remarks section)*
  • Diabetes or high blood sugar? (If yes, please give the details on the Remarks section)*
  • Amputation due to disease or other medical condition? (If yes, please give the details on the Remarks section)*
  • Ataxia, transverse myelitis, Myasthenia Gravis, Autoimmune Disorder such as Lupus, Blindness, or Post Polio Syndrome? (If yes, please give the details on the Remarks section)*
  • Parkinson's Disease, Muscular Dystrophy, Huntington's Chorea, Motor Neuron Disease, Lou Gherig's Disease (ALS) or Multiple Sclerosis? (If yes, please give the details on the Remarks section)*
  • For the past 5 years only, any shortness of breath, dizzy spells, unconsciousness, headaches, or memory loss? (If yes, please give the details on the Remarks section)*
  • • In the past 10 years, have you used marijuana, cocaine, heroin, or any other illicit drug or controlled substance, been advised by a physician to discontinue or reduce alcohol or drug intake, used drugs not prescribed by a physician, or been a member of a support group such as NA or AA?*
  • • In the past 5 years, have you consulted with a physician other than your personal physician or had x-rays, electrocardiograms, heart catheterization, mammograms or other diagnostic tests, except those related to Human Immunodeficiency Virus (AIDS Virus); Or been admitted to a hospital, or advised by a member of the medical profession to enter a hospital for observation, operation or treatment of any kind?*
  • • Do you have any pending appointments with any medical professional?*
  • • Has a parent or sibling been diagnosed or treated by a health professional for cancer, heart disease, Huntington's Disease or polycystic kidney disease?*
  • • Do you currently use or require use of any mechanical or medical devices such as: wheelchair, walker, multi-prong cane, hospital bed, dialysis machine, respirator oxygen, motorized cart or stair lift?*
  • • Do you currently need help, assistance or supervision for: bathing, eating, dressing, toileting, walking, transferring, or maintaining continence?*
  • • Do you currently need help, assistance or supervision in: taking medication, doing housework, laundry, shopping or meal preparation?*
  • • During the past 5 years have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: Falls, Paralysis, Numbness, Tremors, Imbalance, or any condition which causes limited motion?*
  • • During the past 5 years have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: Falls, Paralysis, Numbness, Tremors, Imbalance, or any condition which causes limited motion?*
  • • During the past 5 years have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: memory loss, confusion, amnesia?*
  • • Are you taking any medications?*
  • • Are you using any type of product containing tobacco or nicotine within the last 5 years?*

  • Agreement and Authorization

    I represent all information in this application or an amendment, including all Social Security Numbers, and any medical exam is complete and true. I understand all such information and this application shall be part of any policy issued.

    I understand and agree that all answers given above and in any medical exam are to the best of my knowledge and belief complete and true. All such answers and this application shall be part of any contract issued.

    I have read the PRENOTIFICATIONS, including the notices required by the Fair Credit Reporting Act and MIB, Inc. ("MIB").

    To the extent allowed by law, I waive all rights governing disclosure of medical exams or treatment. I authorize any medical practitioner or facility, insurer, MIB and any other organization or person that has any records or knowledge of me or my health to give such information to the Company or its reinsurers. I authorize the Company to request a copy of my driving record(s) from the state motor vehicle department. I understand and I authorize the Company, or its reinsurers, to make a brief report of my personal health information to MIB. This authorization is valid for 30 months (or the length of time as per state regulation) from the date signed and a photocopy shall be as valid as the original.

    I also certify, under the penalties of perjury, that the Social Security Number of the Proposed Insured and Applicant/Owner (if different) is correct.

    The Company may make administrative corrections and changes to this application and attach them as an amendment to the policy at issue. Acceptance of any policy issued on this application will ratify and will be notice of any such change made. I understand and agree that: (1) I will notify the Company if any statement or answer given in this application changes prior to delivery and acceptance of the policy; and (2) Except as otherwise stated in any Conditional Receipt, no insurance will take effect unless the first full modal premium is paid and a policy is delivered and accepted while the health and insurability of any proposed insured continues, without material change, to be as represented in the application.

    The Agent taking this application has no authority to make, change or discharge any contract hereby applied for. The Agent may not extend credit on behalf of the Company. No statement made to or information acquired by any representative of the Company shall bind the Company unless set out in writing in this application.

    Any person who knowingly presents a false statement in an application for insurance may be guilty of criminal offense and subject to penalties under state law.

    Benefit Distribution Option Rider Disclosure Statements:

    • Under this rider, all or a portion of the policy's Death Benefit proceeds that become payable will be paid as a set of Benefit Payments to the Beneficiary. The Beneficiary of the policy will not be able to change the terms in which the Benefit Payments are paid out.

    • A request to increase the Policy's base Face Amount in accordance with its provisions which has been underwritten and approved by us may also include a request to terminate the Benefit Distribution Option.

    • In accordance with IRS rules and regulations, a portion of each Benefit Payment is reportable as interest income that may be taxable. We will annually report this interest income to the Beneficiary and the IRS as required.

  • I wish to be interviewed if an investigative consumer report is prepared.*
  • Date*
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